Targeted Bleeding Management Reduces the Requirements for Blood Component Therapy in Lung Transplant Recipients.

OBJECTIVE: Lung transplantation is associated with high rates of bleeding and frequent blood transfusion. The authors aimed to determine if point-of-care coagulation testing (POCCT) reduced transfusion requirements. DESIGN, SETTINGS, AND PARTICIPANTS: A before-and-after cohort analysis conducted at a single tertiary referral center. Ninety-three sequential adult patients between January 2010 and January 2014 undergoing isolated lung transplant without preoperative extracorporeal support were analyzed. INTERVENTION: ROTEM and multi-plate POCCT were introduced on July 1, 2012, with an associated algorithm based on the results. MEASUREMENTS AND MAIN RESULTS: Statistically significant decreases in the proportion of patients receiving PRBCs (87% v 65%; p = 0.015), FFP (72% v 30%; p<0.0001) and platelets (70% v 37%; p = 0.002) were found after the intervention. There were small decreases in median chest tube blood loss at 2 hours (300 mLs v 215 mLs; p = 0.03) and 4 hours (440 mLs v 350 mLs; p = 0.050) but not at 12 hours postoperatively. There were no changes in reoperation for bleeding (9% v 4%; p = 0.158) or in-hospital mortality (6% v 2%; p = 0.617). The cost of blood products administered decreased from a median of $3,935.00 to $991.00 (p<0.001). CONCLUSIONS: Use of POCCT in lung-transplant surgery is associated with significant reductions in blood product use and cost. There were no detectable changes in outcome aside from a small decrease in early postoperative bleeding.

Association between post-sternotomy tracheostomy and deep sternal wound infection: a retrospective analysis.

BACKGROUND: Tracheostomy has traditionally been used as a means of facilitated mechanical ventilation in patients requiring respiratory management following cardiac surgery. However in the clinical setting, the advantages of tracheostomy has been questioned by concerns surrounding evidence of its association with increased risk of deep sternal wound infections (DSWI). The present study sought to evaluate retrospectively our experience with post-sternotomy tracheostomy among cardiac surgery patients and association with DSWI. METHODS: Between July 2003 and June 2013, 11,795 patients underwent open cardiac surgery via sternotomy in our department. Among these, 225 underwent post-sternotomy tracheostomy. Data were obtained by reviewing and analyzing the Cardiac Surgical and Cardiac Intensive Care Unit (ICU) databases for adult cardiac patients. RESULTS: Out of the 11,795 sternotomy patients analyzed, 225 (1.9%) underwent tracheostomy. The overall mortality rate for post-sternotomy tracheostomy patients was 21.3%. DSWI developed in 23 patients (10.2%) of the tracheostomy group. Seven of these 23 patients had DSWI after insertion of tracheostomy. DSWI was significantly higher in tracheostomy versus no-tracheostomy patients (10.2% vs. 0.48%; P<0.001). DSWI was also associated with higher mortality rates compared to non-DSWI patients (11.4% vs. 2.3%; P<0.001). CONCLUSIONS: The present study demonstrated that tracheostomy was an independent risk factor for post-sternotomy DSWI, and that DSWI was a predictor of mortality. For tracheostomy patients, coronary artery bypass grafting (CABG) procedures and longer durations of tracheostomy were strong predictors of DSWI. Across all sternotomy patients, tracheostomy, diabetes, urgency status and blood transfusions were significant risk factors for DSWI. As such, the decision for tracheostomy post-sternotomy should be carefully considered on a case by case basis.